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Saturday, 7 May 2016

So you want to get better at shared decision-making

If you are a teacher, evidence-based practitioner or senior leader and are looking to improve your decision-making processes, then this post is for you. In this post we will be looking at the competences and processes associated with shared decision-making between clinicians and patients. We then go onto explore the implications for education professionals and their decision-making processes. But first I will summarise both my underlying position and associated theory of action.

A summary of my argument and underpinning theory of action (amended from Fullan and Hargreaves, 2012)

Decisional capital - the capital that professionals acquire through structured and semi-structured, practice and reflection - is a core component of a school's professional capital

Decisional capital can be enhanced by school leaders working with colleagues to take advantage of their knowledge, skills and experience.

Decisional capital can be enhanced by teachers, heads of departments and head-teachers engaging in the deliberate practice of their decision-making skills - and this practice may require thousands of hours and a number of years to develop.

Research exists in medicine about how to improve the shared decision-making processes between clinicians and patients

These research findings can be adopted for use in schools to identify the competences and processes required by school leaders - at whatever level - to engage in shared decision-making with colleagues (and potentially pupils).

By using these competences as a check-list school leaders can take action to improve shared decision-making with colleagues.

The use of these competences will lead to an increase in decisional capital within the school and contribute to improved outcomes for both pupils and colleagues.

The health professions and shared
decision-making with patients

One area, which might have potential to support teachers and
headteachers engage in better collaborative decision decision is the work of
Elwyn, Edwards and Kinnersley(1999) - cited by Greenhalgh (2014) - who were
pioneers in the academic study of shared decision-making between doctors and
patients. Elywn, et al (1999) state that clinical decision-making can
be seen as a spectrum – with a paternalistic model at one end of the spectrum
and an informed choice model at the other.As such, shared decision-making sits in the middle.Elywn et al represent the model in figure 1 and which I have amended for a school-setting

Figure 1

Paternalistic

<------->

Shared decision-making

<--------->

Informed choice/individual teacher professional autonomy

-

In the context of schools, this could be likened to a range
of decision-making processes, which had a command and control model at one end
of the spectrum and teacher autonomy at the other.In this context, informed choice involves a
teacher receiving information about possible changes in practice which may
impact upon their classroom practice, but they are professionally autonomous enough to
make and informed decision and choice on how to proceed.As such, shared decision-making is an attempt
to stake out a middle-ground in the decision-making process. If school leaders were to share
decision-making with colleagues when addressing problems, then
the characteristics are likely to be as follows (amended from Elwyn et al 1999
p 478)

Shared decision-making involves at least two participants - maybe the headteacher and the teachers and often others

Both parties - be it leaders and teachers - take steps to participate in the decision-making process

Information sharing is a prerequisite to shared decision-making

The decision - which may be to do nothing - is made, and both parties agrees to the decision.

Given the relational nature of the process, I will now turn
the leadership competences necessary to engage in shared decision-making.The competences required for teachers to
engage in shared decision-making will be explored in a subsequent post.

The competences
necessary to engage in shared decision-making

Edwards et al (2004) identify a number of competencies that
clinicians need to demonstrate in order to engage in shared decision-making
with their patients, and these are illustrated in Table 1.

Table 1 Competences required for shared decision-making

Competence

Description

Define the problem

Clear specification of the problem that requires a
decision

Portray equipoise

That professionals may not have a clear preference about
which treatment option is best in the context

Portray options

One or more treatment options and the option of no
treatment if relevantidentified –
alongside the option of no change

Provide information in preferred format

Identify patients preferences is they are to be useful in
the decision-making process

Check understanding

Of the range of options and information provided about
them

Explore ideas, concerns and expectations

About the clinical condition, possible treatment options
and outcomes

Checking role preference

That patients accept the process and identify their
decision-making role preference

Decision-making

Involving the patient to the extent to which they desire
to be involved

Deferment if necessary

Reviewing treatment needs and preferences after time for
further consideration, including with friends or family member, if the
patient requires

Review arrangements

A specified time to review the decision

Inevitably, there is a not straight ‘read-across’ between
competences required for health professional to engage in shared-decision
making with a patient and those which an educational leader needs to engage in
a shared decision-making with colleagues.That said, there are four aspects of the competences which are worthy
of further consideration by the evidence-based practitioner, and which if
practiced may lead to an increase in the school's decisional capital.

First, the competences provide an easily amended check-list
for decision-makers wishing to engage colleagues in shared
decision-making.In particular, the
competences make explicit the need to: define the problem; identify options; explore the implications of the decision; check shared understanding of the situation; involve colleagues in
decision-making process; and, then making follow-up arrangements.In doing so, it provides decision-makers and
their colleagues with a tool with which they can use to reflect upon the
decision-making process and identify areas for development within a shared
decision-making process.As such, it has
the potential to provide a mechanism for decision-makers to engage in
deliberate practice.

Second, the notion of equipoise is central to the process –
i.e. maintaining a sense of balance, if not neutrality, when outlining the
different options available and their respective advantages and
disadvantages.By displaying authentic
equipoise, this should lead to greater engagement by the colleagues in shared decision-making, resultingincreased levels of decisional capital emerging, as colleagues feel they
have a authentic part to play in the decision-making process.

Third, these competences should help those colleagues who
are leading the decision-making process, to really think through how they want
their colleagues to engage in the process.One of the most misused word in the management lexicon is consultation,
which is often used to mean so many different things – be it the testing of
ideas, genuine consultation where opinions are being sort or on other occasions
if can be conflated with collaboration and co-creation.By using the competences outlined in the
shared decision-making, it should help decision-leaders to be explicit about
the decision-making process, and also allow colleagues to participating in the
process to be clear about their expectations about their involvement in the
decision-making process.If expectations
are aligned this is likely to lead to an increase in the stock of decisional
capital, rather than a decrease.

Fourth, given the increased emphasis on pupil voice and engaging with pupils, understanding the nature of shared decision-making and the associated processes may be an essential first-step in helping a school develop opportunities for 'genuine' pupil voice. Indeed, this notion of accessing pupil voice is an essential component of processes that need to be undertaken by evidence-based practitioner.

And some final words

This post has drawn heavily from practices associated with
evidence-based medicine and which may be anathema to some headteachers and
teachers.Nevertheless, if we can get
past the notion that all evidence-based medicine is nothing more than using
RCTS to tell health professional what to do, then will be able to develop the
skills, knowledge and understanding necessary for effective evidence-based
education, at a rate that is faster than would otherwise be case.And in doing, so we will hopefully bring
about better outcomes pupils, colleagues and the communities that schools serve

References

Elwyn, G.,
Edwards, A., & Kinnersley, P. 1999. Shared decision-making in primary care:
the neglected second half of the consultation. The British Journal of General Practice, 49(443), 477–482.

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Evidence Based Practice : A handbook for teachers and school leaders

About the author

Dr Gary Jones, @DrGaryJones, worked in post-compulsory education for over 25 years. Gary has a doctorate in educational management from the University of Bristol and is interested in evidence-based practice and the implications for school leadership and management. Gary is a Fellow of the Center for Evidence-Based Management and associate of the Expansive Education Network based at the University of Winchester, where he supports teachers engage in evidence-based practice. Gary is also involved in a research project investigating school research leads use of research evidence. Over the last last two years Gary has spoken at a range of conferences including ResearchED Sydney, Cambridge, New York, Glasgow and Goteborg. Gary has also spoken at conferences organised by UKFEchat, the Canons Park Teaching School Alliance and the Expansive Education Network.